Superior outcomes and lower outpatient costs with scale-up of antiretroviral therapy at the GHESKIO clinic in Port-au-Prince, Haiti.

BACKGROUND: Treatment protocols and prices of antiretroviral therapy (ART) have changed over time. Yet, limited data exist to evaluate the impact of these changes on patient outcomes and treatment costs in resource-poor settings. METHODS: We compared patient-level data on outcomes, utilization, and cost for the first 2 years of ART for a cohort of adult patients initiating ART in 2003-2004 and a cohort initiating ART in 2006-2008 at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections clinic (GHESKIO) in Port-au-Prince, Haiti. Costs were measured from the health center perspective. Multivariate analyses were conducted to account for the potential impact of differences in disease severity at baseline. RESULTS: With the exclusion of patients who transferred care, 92% (167/181) of patients in the 2006-2008 cohort and 75% (150/200) in the 2003-2004 cohort were alive and in care at the end of the study period. The mean cost per patient for the 2-year study period was US$723 for the 2006-2008 cohort vs. US$1191 for the 2003-2004 cohort, a cost difference of US$468 (P < 0.0001). The mean cost per patient alive and in care at the end of the 2-year study period was US$744 for the 2006-2008 cohort vs. US$1489 for the 2003-2004 cohort (P < 0.0001). CONCLUSIONS: HIV treatment outcomes in Haiti have improved over time while treatment costs declined by over 50% per patient alive and in care at the end of the 2-year study period. The major drivers in the reduction of treatment costs were the lower price of ART, lower costs for laboratory testing, and lower overhead costs.

Three years experience with the implementation of a networked electronic medical record in Haiti.

Since 2005 we have been developing and implementing an electronic medical record (EMR) that supports both individual and population health care of HIV-infected patients in Haiti. Unreliable electrical power and network infrastructure, cultural differences, variable levels of experience and computer literacy, and the geographic dispersion of the team remain challenges, but the system is now implemented in about 40 sites nationwide providing antiretroviral therapy, and includes records for about 18,600 patients. The need to support country-wide monitoring and evaluation drove early architectural decisions to support linking systems under conditions of network uncertainty. We have found surprising end user acceptance of the system, with the adoption of interactive EMR usage exceeding our expectations and timeline.

Antiretroviral therapy for HIV-1-infected children in Haiti.

BACKGROUND: Data are limited about the effectiveness of pediatric antiretroviral therapy (ART) in low-income countries. METHODS: We report the outcomes of consecutively treating 236 human immunodeficiency virus type 1 (HIV-1)-infected treatment-naive children with triple ART in Port-au-Prince, Haiti, between 1 May 2003 and 30 April 2006. RESULTS: Kaplan-Meier survival analysis at follow-up demonstrated that 191 children (81%) remained in care, 21 (9%) were dead, and 24 (10%) were lost to follow-up. Independent baseline predictors of mortality were age <18 months, CD4(+) T cell percentage < or =5%, and weight-for-age Z score (WAZ) less than -3. Twelve months into ART, 56% of tested subjects had undetectable HIV-1 RNA loads. Median CD4(+) T cell percentages at 12 months increased by 15%, 11%, and 5% in children with baseline percentages of < or =5%, 6%-24%, and > or =25%, respectively (P<.01). The median WAZ at 12 months increased by 1.0, 0.6, and 0.2 in children with baseline WAZ less than -2, -2 to -1.1, and -1 or more, respectively (P<.01). CONCLUSION: With continuous donor support, trained providers, and the availability of pediatric antiretroviral drug formulations, it proved feasible to deliver pediatric ART in Haiti. The effectiveness of this program should encourage efforts to make ART available for HIV-infected children in poor countries.